Delayed Surgical Care and Orthopedic Trauma Outcomes in Ethiopia: A Systematic Review

Trauma is one of the leading causes of morbidity and mortality worldwide, resulting in approximately 6 million deaths and leaving another 40 million individuals with permanent injuries each year [1,2]. Strikingly, the incidence of trauma-related deaths each year outnumbers that of HIV/AIDS, tuberculosis, malaria, and COVID-19 combined [2]. This burden disproportionately impacts low- and middle-income countries (LMICs), as roughly 90% of trauma-related deaths occur in these nations [2]. Comparisons of mortality rates following traumatic injuries among underdeveloped, developing and developed countries found that limited access to orthopedic and trauma care services is one of the primary contributors to the disproportionate trauma burden on LMICs [3]. The operational workflow of these health care systems also presents substantial challenges on surgeons operating in these settings. Key obstacles to providing trauma care in these systems include significant resource limitations, demand for trauma care exceeding these systems’ capacity to meet these caseloads and having to resort to triaging surgical patients based upon equipment availability [1].

While the health care systems in developed countries have seen decreasing trauma-related caseloads in recent years, health care systems in LMICs continue to face increasing caseloads, without a proportional expansion in infrastructure or resources to meet these demands [4]. In 2025, the trauma fatality rate in Ethiopia was 26.7% per 100,000 individuals, which is one of the highest trauma-related mortality rates of any country in the world [5].  Previous studies have noted challenges within Ethiopia’s trauma system, including gaps in access to medical and pharmaceutical equipment, limitations in ambulance coverage, and availability in organizations of emergency and trauma services [5,6]. The quality and effectiveness of trauma care in Addis Ababa, the capital city of Ethiopia, has been shown to vary significantly across hospitals primarily due to disparities in access to resources [6,7]. Addressing these barriers requires systemic improvement in surgical infrastructure to improve workflow, expanding rehabilitation services for optimized post-operative care, and increasing access to medical equipment so patient triaging can be based upon clinical urgency as opposed to resource availability [1].

A recently published scoping review examined orthopedic trauma surgical timelines across Sub-Saharan Africa, identifying widespread delays to operative care and characterizing key systemic barriers contributing to these delays across the region [8]. While that review provided a comprehensive regional overview of access and timing, it did not evaluate how surgical delays influence patient-level postoperative or functional outcomes. Building on this foundational work, the present systematic review narrows its focus to Ethiopia and shifts from a descriptive mapping of delays to an outcome-oriented analysis of their clinical consequences.

While many barriers to trauma care in LMICs, and Ethiopia individually, have been identified, it is important to identify interventions that can increase these institutions’ ability to provide trauma care. The sequalae of delayed orthopedic trauma care can be life-altering and even life-threatening, which highlights the clinical significance of this topic. A study was done in 2019 that found there were 178 million new fractures, 455 million cases of acute or long-term symptoms following a fracture, and 25.8 million years lived with disability (YLDs) in that year alone [9]. The purpose of this systematic review is to evaluate the association between delays from injury to surgical intervention and postoperative and functional outcomes among orthopedic trauma patients in Ethiopia. By transitioning from a regional, descriptive analysis of surgical delays to a country-specific, outcome-focused evaluation, this study aims to clarify the clinical consequences of delayed care and inform targeted, contextually appropriate interventions in low- and middle-income settings.

Literature Search

A systematic review was conducted following PRISMA-2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A protocol was registered at PROSPERO prior to the conduction of this review. A comprehensive search in the PubMed, Cochrane, Web of Science, African Index Medicus, and Global Health Journal databases was conducted for English-language studies that involve orthopedic trauma surgeries in Sub-Saharan Africa. The search terms used in this search are listed in Table 1. The search strategy for this systematic review was adapted from a previously published scoping review of orthopedic trauma in Sub-Saharan Africa, with modifications to focus exclusively on Ethiopia.

Study Eligibility criteria 

Inclusion criteria consisted of studies containing patients who underwent orthopedic trauma surgeries, reported “time to surgery” and focused on outcomes in Ethiopia. All eligible papers were published in the English language between January 2010 and January 2025. Studies were excluded if they did not involve surgical intervention, lacked an orthopedic trauma focus, or were published before 2010. Multi-country studies were included if they reported fracture-specific outcomes relevant to the review objectives and reported data from sub-Saharan African sites. Orthopedic trauma is defined as any injury caused by some external force, such as a severe fall, a serious accident, or even a violent attack [10]. Orthopedic injuries are defined as injuries to anatomical structures of the musculoskeletal system, including bones, cartilage, joints, ligaments, muscles, and tendons. Complex trauma cases, such as high-energy injuries with both orthopedic and neurological involvement, were considered if orthopedic stabilization was a primary component of surgical management.

Study Selection and Data Extraction 

Following the database search, two independent reviewers (L.F. and M.L.) screened the titles of all retrieved articles using the inclusion and exclusion criteria. Articles that passed title screening underwent abstract screening, followed by full-text review. After each stage, the reviewers compared their lists of included and excluded articles. Conflicts were resolved through independent re-review and discussion.

Final data extraction was performed independently by multiple team members (L.F. and M.L.) using a standardized Excel spreadsheet stored on a secure server. Extracted data included study characteristics, population demographics, type and timing of surgical intervention, post-surgical outcomes, and barriers to care. Barriers to timely surgery were extracted from the results and discussion sections of each included study, based solely on factors reported as inherent to that study. For the purposes of this study, “late surgery” was defined as operative intervention occurring more than 72 hours after injury. This threshold aligns with commonly reported cutoffs in trauma literature for complications and functional outcomes [11] . Included studies reported early surgical management as debridement within the first 6 hours and fracture fixation within 24 hours, with outcomes stratified according to these intervals. Variations in timing thresholds across studies are described and considered in the interpretation of results.

All data used in this study were secondary and do not represent direct policy prescriptions for Ethiopia or its institutions. To ensure contextual relevance and cultural sensitivity, the review incorporated structured input from several practicing Ethiopian clinicians, including orthopedic surgeons and general practitioners with experience in trauma care. These clinicians independently reviewed the interpretation of findings and provided feedback on clinical applicability, contextual accuracy, and feasibility within Ethiopian healthcare settings. While no Ethiopia-based institutional affiliations were formally included and safety and logistical considerations prevented formal co-authorship, their contributions helped ensure that the findings are clinically relevant, appropriately contextualized, and practically useful. Descriptive statistics were used to summarize study characteristics, and qualitative synthesis was performed to identify recurring themes, patterns of delay, and contributing factors affecting access to timely orthopedic trauma care. Due to substantial heterogeneity across studies, results are presented descriptively, and all reported effect estimates represent study-level associations from individual studies rather than pooled estimates.

Critical Appraisal

The quality of all included studies was assessed by two independent authors (L.F. + M.L.) using the Methodological Index for Non-Randomized Studies (MINORS) tool (Table 2). The scoring for each question includes a zero if not reported, one if reported but insufficient, and two if reported and sufficient. The maximal score for a comparative study is 24 points, and 16 points for a non-comparative study.

In this review, 1,297 studies were identified in the initial search and 1,149 studies were screened (Figure 1). Eight studies were included (8 of 144 full-text articles assessed for eligibility, 5.56%) and are shown in Table 2. Two Level II studies, 4 Level III studies, and 2 Level IV studies were included. All 8 studies were non-comparative in design, and the mean critical appraisal is 10.25 with a range of 9 to 12.

Study Characteristics

Eight studies were included in the analysis, seven of which reported exclusively on Ethiopia, while one study included Ethiopia in combination with two other countries. In 1,260 patients (1,022 males, 238 females), 1,264 injuries were reported, including 973 fractures. Six studies reported on the mechanism of injury. Road traffic accidents were the most common, involving 293 patients, followed by gunshot or bullet injuries in 239 patients and falls in 78 patients.

Injuries and Surgical Management

Fractures were reported in all eight studies, including the femur (4 studies), tibia (4 studies), femur and tibia (1 study), and multiple anatomical sites (1 study). One study reported on non-fracture musculoskeletal injuries including sprains and strains. Surgical management included intramedullary nailing (5 studies), external fixation (1 study), plate and screw fixation (3 studies), internal fixation (7 studies), open reduction (2 studies), and other non-specified surgical interventions (2 studies).

Time from Injury to Admission to Surgery

Across the three studies reporting time from injury to hospital admission, many patients presented within 24 hours (Table 3). Early admission (3-7 days) was less commonly reported, ranging from 2.1% to 16.7%.

The interval between hospital admission and surgical intervention varied widely across the four studies (Table 3). Early surgery, defined as occurring within 24 hours, ranged from 14% to 69% of patients, with one study reporting 70% within the first week. Surgery was reportedly performed within 24-72 hours accounted for 18-52.6% of patients, highlighting that delays of one to three days were common. Late surgery, occurring after 72  hours or beyond 3 days, was less frequent, generally reported in 5-15% of patients, although one study noted 28% of patients operated on in the second week.

Time from Injury to Surgery and its Outcomes

Five studies reported time from injury to surgery, with mean times ranging from 4.1 to 22.5 days (Table 3). Standard deviations were highly relative to the mean in most studies (e.g., 9.83 ± 12.15 days, 48.84 ± 66.45 hours), indicating variability in patient experiences. Shorter mean times were approximately 4-9 days, while longer mean times were approximately 19-22 days.

Five studies evaluated the relationship between delayed time to surgery and worse outcomes (Table 3). Four studies reported a significant association between delayed time to surgery and worse outcomes, while one study reported no association. Of the four supporting studies, delayed surgical management, particularly presentations beyond 72 hours, was linked to higher odds of infection, prolonged hospital stays, increased economic burden, and poorer functional recovery. One study found that delayed nailing (15 to 29 days) increased the risk of knee pain. Another reported that patients admitted more than 24 hours after injury had nearly threefold higher odds of infection (AOR = 2.895, 95% CI 1.402-5.977; p = 0.004), and those receiving IV antibiotics after 3 hours had similarly elevated infection risk (AOR = 2.924, 95% CI 1.160-7.370; p = 0.023). In contrast, a single study found no significant association between time to surgery and outcomes such as complication rate, radiologic union time, or quality of reduction.

Barriers

Seven out of the eight studies identified barriers to medical treatment (Figure 2). The most common issues included lack of surgical equipment (4 studies), limited hospital or operating room availability (2 studies), and insufficient imaging equipment or staff (1 study). Financial barriers such as inability to pay for implants or initial care, lack of insurance, and work obligations were noted in three studies. Poor pre-hospital services and ineffective ambulance systems were each reported in two studies, while one study identified war as a major barrier to care.

Infection

Four studies reported overall infection rates ranging from 5.6% to 33.19%with two studies reporting only aggregate infection rates (5.6% and 8.3%) without stratification or risk factor analysis. The highest infection rate (33.19%) and all detailed multivariable analyses were derived from a single study of open tibial fractures, in which 52.6% of infected cases required operative irrigation and debridement. In this study, independent predictors of infection included delayed intravenous antibiotic administration (>3 hours post-injury; AOR = 2.924), delayed wound closure (>7 days; AOR = 3.524), delayed hospital admission (>24 hours post-trauma; AOR = 2.895), and use of external fixation compared with internal fixation (AOR = 2.817).

Union

Four studies reported on time to union. In unstable intertrochanteric fractures, a single study reported a mean time to union of 3 months for PFNA and 3.4 months for DCS. A single study reported full union in 97.3%, mean 105 days range of 29-605 days. One study assessed union using the Radiographic Union Scale for Tibial Fractures (RUST) and found a mean RUST score of 11.75 ± 0.77 (range: 9-12), with scores ≥9 indicating radiographic union. In another study, the mean time to union was 4.63 months, with progressive union rates: 4 months: 60% (36 patients) achieved bony union; 5 months: 25% (15 patients); 6 months: 8.3% (5 patients); >6 months: 6.7% (4 patients).

Two studies reported on malunion. A single study reported that 77% had varus collapse following unstable intertrochanteric fractures and another single study reported that there was 17% of patients with post-operative malalignment following tibial fracture. Three studies reported on non-union rates, including 5.6%, 1.8%, and 7.1%.

Re-Operation, Amputation, and Length of Hospital Stay

Four studies reported re-operation rates. Among patients with postoperative infections, one study found that 41 of 78 patients (52.6%) required surgical debridement and irrigation. Another study reported 2 re-operations (11.1%), while a third described 3 patients requiring implant removal with incision and drainage due to deep infection. Revision surgery for fracture-related complications was reported in 10 cases (6.2%). Amputation was reported in patients whose initial management occurred more than two weeks after injury in one study.

Length of hospital stay was reported in five studies and varied by fracture complexity and timing of presentation. For uncomplicated fractures, hospitalizations ranged from 2 to 3 days. Mean durations ranged from 8.5 days (range: 3-29 days) to 10.2 days for proximal femoral nail (PFNA) fixation, compared with 4 days for dynamic condylar screw (DCS) fixation. One study reported a median stay of 5 days (IQR: 3-10). Longer hospitalizations were observed in patients presenting more than 72 hours after injury.

Functional Outcomes

Five studies reported on functional outcomes. One study comparing fixation methods found that the PFNA group achieved a higher mean Harris Hip Score (84.9) compared to the DCS group (70.0), a statistically significant difference (P = 0.001). Excellent outcomes (HHS 90-100) were achieved in 64.5% of PFNA patients versus 5.0% of DCS patients. Another study assessing lower limb motion reported no significant difference in knee flexion (P = 0.062) between injured and uninjured limbs but found significant reductions in knee extension (P = 0.032), ankle dorsiflexion (P = 0.003), and ankle plantar flexion (P < 0.001). Overall, 87.5% of patients achieved good or excellent outcomes. A third study found that earlier surgical management (<24 hours) was associated with better functional recovery on multivariable Cox regression analysis. One study using Neer’s criteria at 6 months reported 78.3% good-to-excellent outcomes and 21.7% fair-to-poor outcomes; closed distal femur fractures and regular follow-up were independently associated with excellent results. Finally, one study noted  that all patients regained full knee range of motion postoperatively, except one who experienced temporary stiffness (ROM < 90°) but recovered full motion by 18 months.

Two studies reported postoperative pain outcomes. One study found that 36.4% (40/110) of patients experienced knee pain at 6-month follow-up after retrograde SIGN nail fixation. Delayed fixation (15-29 days post-injury) was associated with a 4.2-fold increased risk of knee pain (AOR = 4.23) compared to fixation within 15 days. Another study reported that 16.7% (10 patients) had persistent pain at 6 months

Return to Work

Two studies examined return to work. In one study, all but two patients returned to their preinjury occupations. In another study, economic burden was significantly worse in a patient who had a prolonged stay of >72 hours.

Time to treatment is a critical determinant of outcomes in orthopedic trauma, however, information on time to intervention is scarce in Ethiopia. Of 1,149 studies screened, only eight met inclusion criteria, with road traffic accidents identified as the leading cause of injury and femur and tibia fractures most frequently reported. Delays beyond 24 to 72 hours were consistently associated with higher infection rates, prolonged hospitalization, increased economic burden, and poorer functional recovery. Systemic barriers such as lack of surgical equipment, limited pre-hospital services, ineffective ambulance systems, and financial constraints further impede timely care. The limited scope of existing research suggests that many patient experiences and treatment delays remain undocumented. Unlike previous literature, this review provides a focused synthesis of Ethiopia-specific data on delays to orthopedic trauma care, highlighting the factors driving variability and the gaps in existing evidence.

Orthopedic trauma in Ethiopia predominantly affects young adult males, a pattern reflected in this study, with profound social and economic risk. Young men, often the primary earners, bear the majority of injuries, leading to interrupted employment, lost income, and long-term disability that reverberates through households and communities [20,21,23]. Road traffic accidents remain the leading cause of injury and mortality, representing a persistent public health challenge, and many victims experience neglect or delays in care [23]. Reported cases likely capture only a fraction of the true burden, as countless individuals never reach formal medical care and remain invisible to the healthcare system [22,24]. Further, structural and societal barriers, including inadequate road infrastructure, unsafe pedestrian and cycling pathways, limited and unreliable public transport, long travel times, high costs, and safety concerns, further delay or prevent timely care [6]. The burden is further compounded by gunshot and bullet injuries, particularly in regions affected by armed conflict, which disrupt hospital operations, destroy livelihoods, and weaken healthcare infrastructure, producing stark inequities in access to care [25]. The predominance of fractures in hospital presentations underscores their severity and the necessity for surgical intervention, yet this pattern likely reflects a selective reporting bias, as less severe musculoskeletal injuries may never reach formal care, leaving much of the true burden unrecognized [26,27].

Time from injury to hospital admission in Ethiopia is shaped by geographic, infrastructural, and systemic challenges that have direct implications for patient outcomes. Access to hospitals is especially limited in rural areas, where long distances and poor transportation options delay timely care [21,29]. Patients frequently rely on ambulance services, yet utilization is low due to perceived long wait times and language barriers across a linguistically diverse population [30,31]. Even where ambulances are available, most timely arrivals occur in urban or well-resourced regions, while rural patients often experience significant delays [21,29]. While a large proportion of  patients reach hospitals within the first 24 hours, a notable proportion present days after injury, reflecting inequities in access and leaving many victims unaccounted for in hospital-based data [5]. Contributing factors include insufficient medical equipment, poorly organized emergency departments, and systemic inefficiencies, which can prolong emergency room stays without indicating substandard clinical care [5,32]. Such delays are particularly impactful in Ethiopia, where road traffic accident mortality remains high due to both the severity of injuries and treatment delays [7,33].

In this review, many patients were admitted within 24 to 72 hours of injury and then experienced delay in treatment initiation even after reaching the hospital [27]. Reported delays varied widely across studies, reflecting differences in hospital infrastructure, availability of surgical resources, workforce capacity, and the ability of facilities to report or document patient treatment accurately, particularly in under-resourced or rural settings. Some studies reported delays of several days even in urban centers, while others found shorter times to surgery in better-resourced hospitals. DeMaio et. al emphasized that that low- and middle-income countries like Ethiopia continue to struggle with inadequate access to safe, high-quality surgical care, compounded by a shortage of fellowship-trained orthopedic traumatologists [28]. Several studies in this review echoed a lack of essential surgical resources including but not limited to imaging equipment, fracture tables, and implants required for fixation procedures [1,13,14,16]. Without these basic tools, surgeons face workflow challenges that delay care, lead to cancellations, and leave patients to bear the consequences [35]. Structural and workforce limitations further compound the problem, with overcrowded operating rooms, poorly designed perioperative spaces, and persistent nursing shortages [34]. Beyond infrastructure, the economic burden on patients remains a major barrier to care, as many must pay for their own implants, a devastating expense in a country where many rely on daily wages for survival [17,19,35]. One in four surgical patients in Ethiopia experience catastrophic health expenditures, reflecting deep financial vulnerability and the risk of impoverishment due to surgical costs [36].

Post-surgical outcomes in orthopedic trauma depend on the timeliness of intervention, the availability of surgical resources, and the effectiveness of follow-up care. Evidence suggests that delayed presentation, postponed antibiotic administration, and late wound closure significantly increase the risk of post-operative infection, which emphasizes the importance of rapid and coordinated trauma care [16]. At the same time, patients who present late or sustain more complex injuries often experience prolonged hospitalization, which can be further affected by comorbidities, malnutrition, or functional decline [37,38]. In settings with limited healthcare infrastructure, longer stays strain resources and limit the capacity to treat additional patients, creating a cycle that impedes overall trauma care delivery [32]. Functional outcomes are favorable with timely surgical intervention, but recovery can be compromised when prompt treatment and structured rehabilitation are lacking. Many fractures achieve union, but delays in care or late presentation can significantly affect bone healing and alignment. Considering economic impact, many patients eventually return to pre-injury employment but delays in surgery and recovery prolong disability and increase financial burden. In a study about trauma survivors in Ethiopia, Ahmed et. al reported that 87% of patients were engaged in manual labor, yet only 59% had returned to work at one year, with 61% reporting residual disability [20]. Another recent study conducted in 2020 suggests that follow-up has proven to be a practical and low-maintenance solution for Ethiopian surgical patients [39]. Factors that support faster return to work include shorter hospital stays, absence of functional restrictions or chronic illness, type of employment, access to compensation, and personal motivation during recovery [21].

In Ethiopia, optimizing time from injury to surgery is an important aspect to consider with orthopedic trauma care, as it can determine the difference between recovery and lifelong disability. Most surgery-ready facilities are concentrated in urban areas, leaving Ethiopia’s 80% rural population with limited access to timely care, a gap that demands innovative solutions to bring high-quality services closer to those in need [29]. Gebregzi et al. al suggest that strengthening the health system through the implementation of electronic medical records, ongoing workforce training, and targeted investment in infrastructure is critical to ensuring safe, timely, and effective surgical care [34]. While Ethiopia has increased its surgical workforce density in recent years, it remains essential to continue developing sustainable surgical systems that empower local professionals and optimize efficiency [40]. Trauma prevention, can be addressed in part through road safety initiatives, and building resilient surgical infrastructure is essential to respond to conflicts or other emergencies [22]. Providing surgical equipment, training healthcare professionals, and investing in existing facilities while expanding capacity are essential steps toward sustainable, locally led change [1,34].

Limitations

This review has important limitations to consider. The included studies were heterogeneous in design, methodology, and reporting standards, particularly regarding the definition and measurement of “time to surgery.” Variability in reporting intervals (injury-to-admission, admission-to-surgery, or injury-to-surgery) limited the ability to directly compare findings across studies or perform meta-analysis. Several studies reported mean time to surgery with large standard deviations, suggesting skewed distributions and limiting the interpretability of mean values when median and interquartile range were not available. All data used in this study were secondary and do not represent direct policy prescriptions for Ethiopia or its institutions, and the review does not include Ethiopia-based institutional affiliations, which may limit contextual insight into the findings. Most included studies had small sample sizes and were non-comparative in design, which may reduce statistical power and generalizability and increase the risk of both type I and type II error when interpreting reported associations. The predominance of single-center studies and potential publication bias may limit representativeness, as regions with limited research infrastructure or poorer outcomes are likely underreported. Lastly, variations in clinical resources, patient populations, and healthcare infrastructure across study sites make it difficult to isolate time-to-surgery as an independent predictor of outcomes.

In Ethiopia, delays in surgical intervention for orthopedic trauma commonly influence patient outcomes, although available evidence is limited. Road traffic accidents were the leading cause of injury. Although many patients reached hospitals within 24 hours, significant surgical delays, often exceeding one week, were commonly associated with higher infection rates, prolonged hospitalization, increased economic burden, and diminished functional recovery. Early surgical intervention, within 24 to 72 hours of injury, are associated with improved outcomes. Persistent barriers such as limited surgical equipment, inadequate operating room access, financial constraints, and weak pre-hospital systems continue to impede timely care. Addressing these challenges through improved trauma infrastructure, expanded surgical capacity, and streamlined referral and triage systems is could reduce preventable morbidity and improve orthopedic trauma outcomes across Ethiopia.

This manuscript utilizes literature identified in a previously published scoping review by the authors [39]. The scoping review served solely to identify relevant studies. The present work is a separate systematic review with a focused research question, different variables of interest, formal quality assessment, and a country-specific analytical framework.

Funding

This study received no external funding.